I will end today these discussions on health care by looking at mental health and finally reminding people that all this talk of telemedicine and remote medical microchips will come to all Americans ----not just what you think are the underserved in Baltimore, Maryland. We need everyone in the US shouting loudly that JOHNS HOPKINS SHOULD NOT BE DOING THESE J-CHIP POLICIES!

Below you see what your Baltimore City pols running as Democrats and serving as Hopkins neo-conservatives have been doing-----this is what deregulating health care looks like. It breaks down the meaning of doctor and subprimes it to mean lots of different things....just as they are doing to the meaning of teacher and public schools. We already know remote medicine can take place anywhere in the world so like corporate call centers based in India-----these controls can exist in any global corporate location attached to US global health care. So, all those jobs, jobs, jobs, these policies are supposed to create will again be temporary----part time------same with small businesses and non-profits. This will be a few decades from now as they build the internet capacity for global health tourism-----so initially, they will just bring foreign doctors and workers to do these jobs. Meanwhile, these health systems growing nationally will rake in what is several billions of dollars in Medicare and Medicaid while rarely seeing people. You have to imagine doctors in Maryland spending time on telemedicine patients in California and then expand it globally to see access to care for main street disappearing with quality falling to dangerous.

THIS IS WHAT OBAMA AND CLINTON NEO--LIBERALS CALL EFFICIENT, DATA-DRIVEN, COST EFFECTIVE HEALTH CARE. DON'T VOTE REPUBLICAN BECAUSE ALL THIS IS REPUBLICAN HEALTH POLICY AND NONE OF THIS IS CONSTITUTIONAL---

All Baltimore City Council and Mayor has to do is enforce Federal laws surrounding War on Poverty, equal protection, Medicare and Medicaid, and Federal public health regulations and VOILA----Johns Hopkins cannot treat Baltimore citizens like citizens in Cambodia.

Remote Medicine Tests Physician Licensing Rules

March 07, 2014

By Christine Vestal

Psychiatrist Terry Rabinowitz consults with nurse Leslie Orelup at Helen Porter Nursing Home in Burlington, Vt. States are considering an interstate compact that would make it easier for doctors to practice telemedicine across state lines. (AP)

Demand for doctors – whether in person or via a computer screen – is expected to surge as millions more Americans become insured under the Affordable Care Act. About 10 million people already rely on telemedicine, often from doctors who live in another state.

As a result, more physicians are applying for medical licenses in multiple states – a costly and time-consuming proposition for some. Without a license to practice medicine in the patient's state of residence, both doctors and patients may be at legal risk.

Many states are embracing telemedicine by encouraging it in their Medicaid programs and requiring private insurers to pay for it. But they have made little progress in removing medical licensing barriers that proponents of the technology say have kept doctors and hospitals from expanding even more.

Telemedicine was once the purview of small town doctors who needed to consult with specialists available only in larger urban areas. Today, telemedicine technology is even being used to conduct surgeries using robotics, typically only in emergency situations such as during war.

Most telemedicine consists of video teleconferencing between a doctor and a patient. Doctors also routinely use telemedicine technology to transmit and discuss diagnostic images and to remotely monitor patients with chronic diseases so they don't have to leave their homes or nursing facilities.

For some consumers, it is the primary way they receive medical care. Using Skype on a computer or FaceTime on an iPhone, patients discuss their symptoms and show their doctors any visible evidence of their conditions, such as a swollen eye or skin rash. Patients most often conduct these consultations from home or their workplace. In some cases, patients go to a medical facility and use high-end, secure equipment to teleconference with a doctor in another location.

Much of the growth in telemedicine is expected to be in remote monitoring of patients with heart and lung diseases and diabetes, who have recently been discharged from a hospital. The aim is to detect health problems early enough to prevent them from being sent back to the hospital.

States have argued that easing licensing requirements could jeopardize patient safety. If doctors practice in a state without obtaining a license there, regulators maintain that they have no power to conduct an investigation or explore a consumer complaint. Also, these doctors would not benefit from any legal protections the state may have against malpractice lawsuits.

Proponents of telemedicine argue that since doctors take standardized national exams and most requirements are set by federal agencies such as the U.S. Department of Health and Human Services, states should recognize other state licenses. They say state medical boards are simply trying to shield doctors from out-of-state competition and preserve state revenues from licensing fees.

At What Cost?The cost to doctors of obtaining multiple licenses is estimated at $300 million a year, according to Gary Capistrant, public policy director at the American Telemedicine Association. That does not include the fees doctors pay for their primary licenses in their home states. For hospitals and medical practices that operate in multiple states, the burden of licensing limits the number of doctors who are willing to participate, he said.

State medical licensing fees vary from a low of $150 in Michigan to a high of $1,290 in Rhode Island. Most range from $200 to $600, with lower renewal fees. Of the roughly 850,000 practicing physicians in the U.S., 17 percent have at least two state licenses and 6 percent have three or more, according to a 2010 survey.

Now, under pressure from major telecommunications and health care firms that want to create nationwide telemedicine businesses, state medical licensing boards are set to consider an “interstate medical licensure compact” that would give doctors and patients legal protections in any state that signs on. Patients would have greater protection than exists now, because states that join the compact would share data on any ongoing investigations of licensed doctors.

The proposal, to be considered at the annual meeting of the Federation of State Medical Boards in April, would expedite the licensing process for doctors who want to practice across state borders. Similar interstate compacts have been used for other types of licensing, including driver's licenses.

Even the most pro-telemedicine states have not yet taken a stand. The compact, which was developed by a task force of 22 state medical boards, may represent the first step. Lisa Robin, chief advocacy officer for the federation, expects there will be some early adopters. “I believe there will be some proliferation,” she said. “We'll see in April.”

In addition to reimbursement and licensing, proponents say states need to define what types of telemedicine may be practiced, whether patients need to sign special consent forms and when doctors can prescribe medications remotely. Several state legislatures are considering those issues this year.

Growing PainsSince its beginnings in the mid-1980s, the number of patients cared for through telemedicine has risen from a few thousand to an estimated 10 million people in rural as well as urban settings. The vast majority of the growth has occurred in the last decade, according to the American Telemedicine Association.

Market analyst IHS estimates U.S. telemedicine spending will grow to $2.2 billion in 2018 from $240 million this year. A new lobbying group, the Alliance for Connected Care, formed last month to promote federal and state policy changes to spur the industry's growth. Led by former U.S. Senate Majority Leaders Tom Daschle, Democrat from South Dakota, and Trent Lott, Republican from Mississippi, the group's members include health care and technology giants Verizon, WellPoint, CVS Caremark and Walgreens, as well as smaller companies Teladoc, HealthSpot, Doctor on Demand and MDLIVE that offer online access to medical services.

Widely considered an effective way to reduce overall health care costs, increase patient access to care and improve overall health, telemedicine has broad support within state governments and Congress. At least five bills designed to further its use have bipartisan sponsorship in Congress.

“Until we are able to attract more physicians to rural communities and tighten the access gap,” one bill's sponsors wrote, “the next best alternative is to use technology to connect health professionals with underserved populations – rural and urban – through telehealth networks.”

Four of the bills under consideration would allow doctors who provide services under Medicare and TRICARE (the insurance plan for military personnel), and accompany sports teams when they travel from state to state to have just one state license. The U.S. Department of Veterans Affairs, a vigorous proponent of telemedicine, already considers a medical license in one state sufficient to provide services in all 50 states.

For soldiers returning from Iraq and Afghanistan, telemedicine is the primary way they've been receiving medical care already.

“We're fast becoming a 24/7 world,” said Capistrant. “People don't just get sick 9 to 5. Many work at night. For some, finding a doctor that speaks their language can be a problem. Technology can help deal with some of those issues and we should use it.”

Who Pays?The biggest issue at the federal level is that Medicare reimburses only for telemedicine services on a limited basis. To qualify, patients must meet a narrow definition of residing in a rural area, and even then the federal health plan for the elderly and disabled will pay for only certain types of services.

The other huge government health program, Medicaid, pays for a wide range of telemedicine procedures for the poor, according to the Center for Connected Health Policy, in all but Iowa, Massachusetts, New Hampshire, New Jersey and Rhode Island, where health care plans for the poor do not currently cover telemedicine services.

Only 21 states and the District of Columbia require private plans to cover telemedicine, despite strong support from employers who want to see the cost of premiums go down as telemedicine is used more often to keep people out of hospitals. An added benefit for employers is that telemedicine allows workers to receive care without taking time off from work to go to a doctor's office.

_____________________________________________While Congress was taking gun control issues to the floor they were at the same time touting the mental health policy they were installing in ACA....after all, most mass shootings are by people having mental illness who most often cannot get help because America's mental health system has been reduced to PHARMA dispensation. Below you see where funding is going-----to train school teachers how to identify mental illness-----to send police officers out into communities to force people determined a threat to communities into what is yet to be known. Again, as always with the Affordable Care Act----this gives preventative care for mental health which means PHARMA. As I said, Obama and Clinton neo-liberals broadened the definition of depression-----allowed for more mental health PHARMA to be included in health plans. Add to this the plan to use this medical microchip technology for this enhanced preventative care and you have remote dosing for what is now a very broad definition of having a mental illness.

I already have issues with the methodone treatment of heroin addiction---the quality of life from many PHARMA used to treat these broad categories are often impacted. One can see this moving to a place where people never leave where they live and becoming incapacitated with a home health care service checking in every now and then.

The second thing ACA did was make it legal to dose people without their permission. The US has always denied these actions because who determines this need and how debilitating these mental health PHARMA can be----it is a very, very, very slippery slope to people having these policies used against them with no cause----AS AUTOCRATIC DICTATORSHIPS DO WITH DISSIDENTS, ANTI-SOCIAL BEHAVIOR, AND REVENGE FOR GOODNESS SAKE. This is why the US has never allowed forced dosing of mental health meds. Now, given the timing of this law-----the US is becoming autocratic moving to global corporate rule and corporate fascism----THIS IS NOT THE TIME FOR INSTITUTIONS TO HAVE THE POWER OF FORCED DOSING.

Below you see where ACA places more emphasis on drug and alcohol as mental health issues-----and it broadens attention to more severe mental illness. All of this would be good if it were not tied to involuntary treatment defined as simply being determined to need help by institutions----remote microchip dosing----and outsourcing outpatient mental health facilities to private contractors. This article sounds very repressive----we are going to go out and identify people with mental health issues!

THIS IS SERIOUS STUFF FOLKS!!!!!!!!!!!!!

The Affordable Care Act and Expanding Mental Health Coverage

August 21, 2013 at 4:00 PM ET by Cecilia MuñozTwitterFacebookEmailSummary: Health care providers, mental health advocates, and individuals who have personally experienced mental illness came to the White House to talk about the intersection of two important Presidential priorities: the Affordable Care Act and mental health.President Barack Obama delivers remarks during the National Conference on Mental Health in the East Room of the White House, June 3, 2013. Standing with the President, from left, are: Health and Human Services Secretary Kathleen Sebelius, Education Secretary Arne Duncan, and Veterans Affairs Secretary Eric Shinseki. (Official White House Photo by Pete Souza)

Last June, the President hosted the National Conference on Mental Health to talk about how we can raise awareness of mental health issues and make it easier for Americans of all ages to reach out and get help. The President’s Fiscal Year 2014 Budget proposal includes a strong focus on mental health by investing in helping teachers and other adults recognize the signs of mental illness in students and referring them to help if needed; supporting innovative state-based programs to improve mental health outcomes for young people ages 16-to-25; and helping to train 5,000 additional mental health professionals with an emphasis on serving students and young adults.

Dr. Howard Koh, Assistant Secretary for Health for the U.S. Department of Health and Human Services; Christen Linke-Young, Director of Coverage Policy in the U.S. Department of Health and Human Services’ Office of Health Reform; Pamela Hyde, Administrator of the Substance Abuse and Mental Health Services Administration in the U.S. Department of Health and Human Services; and Stephanie Valencia, Special Assistant to the President and Principal Deputy Director of the White House Office of Public Engagement discuss the Affordable Care Act and mental health at the White House, August 21, 2013.

But we know that it’s not enough. If we’re going to help more Americans seek treatment, we also need to make sure they have coverage when they do. That is why implementation of the Affordable Care Act is a major focus of our mental health agenda. Today, health care providers, mental health advocates, and individuals who have personally experienced mental illness came to the White House to talk about the intersection of two important Presidential priorities: the Affordable Care Act and mental health. The gathering focused on the mental health benefits in the health care law and what we all can do to help Americans get the affordable health care coverage – including mental health care coverage – they need.The Affordable Care Act builds on the Mental Health Parity and Addictions Equity Act to expand mental health and substance use disorder benefits and federal parity protections for more than 60 million Americans. New health plans are now required to cover preventive services like depression screenings for adults and behavioral assessments for children at no additional cost. And starting next year, insurance companies will no longer be able to deny health care coverage to anyone because of a pre-existing mental health condition.

This Administration is committed to helping people with mental health and substance abuse issues get the care they need, and the Affordable Care Act is playing an important role in achieving this goal. To learn more about the Affordable Care Act and to sign-up for updates, visit healthcare.gov.

______________________________________________We already know that in the US states are ignoring Federal laws protecting people from this very kind of involuntary dosing with drugs. They do this because they think a President can use Executive Order to install the Federalism Act and that gives states carte blanche to do anything they want----AND THEY ARE. Below you see where this has been going for a few decades and with Affordable Care Act law and funding geared towards mental illness in ways that weaken protection for civil rights and liberties. Add to that the process of remote medical microchips and dosing with people assigned to outpatient facilities that are simply yet another round of privatization to anyone that gets a license. I don't disparage all existing treatment programs and outpatient facilities---what I am saying is now they are super-sizing these situations at the same time they are subpriming the laws that protect people against mental health treatment abuses.

Last week was the culmination of more than a year's worth of advocacy towards the U.N. Human Rights Committee on the issue of forced psychiatric drugging in the United States. The Human Rights Committee is a committee of independent experts elected to review compliance with the International Covenant on Civil and Political Rights, a treaty to which the U.S. is a state party.

Aubrey Shomo, Patricia Bauerle and I spent the week talking to Committee members and holding side events to give information and personal testimonies beyond what we presented in the written shadow report, including global perspectives. We were joined in side events by our colleagues from the World Network of Users and Survivors of Psychiatry, Hege Orefellen from Norway and Jolijn Santegoeds from the Netherlands, as well as Richard Pearshouse from Human Rights Watch and moderators Facundo Chavez Penilla, Disability Adviser to the Office of High Commissioner for Human Rights, and Jorge Araya, Secretary of the Committee on the Rights of Persons with Disabilities. Our international team did amazing work, and was supported by the Geneva-based secretariat of the International Disability Alliance, of which WNUSP is a member. I will write more about what I am learning about shadow reporting, and we will also be sharing video and audio from our presentations, but now I want to report on what happened on Friday in the Interactive Dialogue of the Committee with the United States.

On Friday March 14, 2014, Human Rights Committee member Ms Zonke Majodina from South Africa questioned representatives of the United States government on forced psychiatric drugging. While we await the video archive and transcript, here are my notes of what she said:

Regarding the nonconsensual use of psych medication in psych institutions:

We are told that U.S. constitution constrains the government’s use of nonconsensual treatment & clinical investigations. That they are permitted only in carefully controlled situations & also constitutional safeguards such as federal PAIMI program, and regulations on use of restraint on patients in mental institutions.

On the other hand, information from nongovernmental organizations shows that there is ample evidence that state & local governments routinely apply and allow neuroleptic medications and electorhosck to be applied without informed consent & against their will. It is not limited to psychiatric institutions but allowed in nursing homes for older persons especially those with dementia and people in situations of particular vulnerability such as children in foster homes and prison inmates. New York law permits compulsory treatment of persons confined against their will, in particular where consent lacks capacity to make a reasoned decision. The law also allows for forced drugging in prison and even after release from prisons.

Scientific literature reveals neuroleptic drugs have serious side effects. They are mind altering, and cause shivering, trembling, contractions and all kinds of other physical side effects.

The Special Rapporteur on Torture recently called for an absolute ban on all forced and non-consensual medical interventions against persons with disabilities, including the non-consensual administration of psychosurgery, electroshock and mind-altering drugs such as neuroleptics, the use of restraint and solitary confinement, for both long- and short- term application.

Furthermore the U.S. National Council on Disability recommended, "Laws that allow the use of involuntary treatments such as forced drugging and inpatient and outpatient commitment should be viewed as inherently suspect, because they are incompatible with the principle of self-determination. Public policy needs to move in the direction of a totally voluntary community-based mental health system that safeguards human dignity and respects individual autonomy."

Against this background, I pose the following questions:

Is the U.S. government concerned about this widespread use of nonconsensual psych medication, electroshock and other coercive practices?

Has the U.S. or another state given consideration to imposing ban recommended by the Special Rapporteur on Torture?

What have states done to reform criminal law and procedure, policies and practices against people labeled with psych disabilities including drugging as a condition for release?

Has the President or Congress taken any action regarding the recommendation of the National Council on Disability?

The U.S. representative from the Department of Health and Human Services, Dr Wanda Jones, answered as follows (also my notes):

Ms Majodina asked about nonconsensual medical treatment.

Although US federal law prohibits nonconsensual treatment, it can be provided without consent for life threatening interventions.

This is governed by state law, which cannot violate constitutional provisions on due process, privacy and equal protection of individuals. Professional organizations may also have guidelines on practice.We are concerned. We established the Protection and Advocacy for Individuals with Mental Illness program, which operates in all 50 states, DC, all territories and in consolidated Indian territories. PAIMI supports state-designated projects that are specifically designed to investigate allegations of violations in mental health settings, including seclusion & restraint.

The program reported over eighteen thousand complaints and closed thirteen thousand. About ten thousand were substantiated, of which about a fifth were abuse and a fifth neglect. There were over 6200 rights violations. 2500 cases were not substantiated. Where intervention was substantiated, they achieved positive changes in environmental community or living arrangements. We are constantly working on getting better.

Medicare conditions of participation for hospitals including psychiatric hospitals detail restrictions on the use of restraints including drugs and medications when used to manage behavior or restrict freedom of movement. This implements standard that is set in regulation, monitored by Center for Medicare and Medicaid Services.

The Department also supports the training and development of consumer/peer mental health workers, designated to assist those who are receiving services to access needed services.

We expanded comprehensive community mental health services to children and families, and expanded program of cooperation with the justice system, transitioning into civil society.

The Affordable Care Act will mean one of the largest expansions in substance abuse and mental health treatment services in a generation.

SAMHSA has had a significant impact on culture of treatment environments. Many facilities funded through state grants have reduced traumatizing practices, facilitated recovery and consumer directed care.

Regarding medication and treatment of federal prisoners including those with mental disabilities, a strict set of federal regulations governs the extent to which medication can be administered involuntarily, including an administrative hearing, except in emergency circumstances.

Ms Majodina followed up by saying (from notes taken by a staff person from the secretariat of the International Disability Alliance):

On non consensual medical treatment, I understand there are special rules and appreciate efforts on monitoring at the state level.

But I am still surprised that states have been left to devise their own rules. I’m wondering whether any states have considered the ban which has been recommended by the Special Rapporteur on Torture made February last year, available on the UN website of documents. So given that it is really at state level that there is no compliance with the requirement to prohibit coercive treatments especially in mental health settings, I think the matter cannot just be left, there should be some form of good faith undertakings by federal government that these recommendations by UN bodies is taken seriously also at state level.

The final step will be the Committee's adoption of Concluding Observations and recommendations for the United States.____________________________________________The movement from defining when a person can be involuntarily dosed or committed from doing harm to themselves or others to simply being determined to 'NEED HELP'......IS HUGE.

Already in Baltimore, City Hall has used this ACA funding to send police to homes they identify as having people 'needing help'. I am not sure yet what happens to them. We all understand the frustrations of communities with violence, drug abuse, and mental health issues. The solution was to have public community centers, public health clinics, and public social services staffed well enough to be that source for community. NOT THE POLICE FORCE. I spoke with a young lady whose boyfriend was killed by several police officers sent to a house with just someone giving a tip he had a gun so this entire process will be fraught with injustice. WHEN THEY NEED TREATMENT.

'The bill would require states that get federal mental health grants to change their standards for involuntary psychiatric commitment, allowing people to be hospitalized against their will when they need treatment, not simply when they pose a danger to themselves or others – the standard in about half of states. That change could allow patients to get care sooner, Murphy says'.

The second piece of this is the preventative care taking over in-patient access. This is how we know real mental health policy is being dismantled when people are being denied the ability to spend time with real professionals and instead being outsourced to out-patient treatment and houses that are often staffed with people less trained for such a broad group of people. This is happening because Congress is filled with Clinton neo-liberals who are with Republicans in wanting fast, cheap ways of getting people out of circulation that are determined 'different'. It was Reagan/Clinton neo-liberalism that joined Republicans back in the 1980s and 90s to dismantle and close all public mental health institutions and clinics to send them to prisons and jails----now the same neo-liberals are legislating away civil rights and liberties to such an extent---that anyone can be described as 'needing help'.

Lawmakers, patient advocates and the millions of Americans living with a psychiatric diagnosis agree that the nation’s mental health care system is broken, and on Thursday, Congress will hear testimony on the most ambitious overhaul plan in decades, a bill that has already stirred longstanding divisions in mental health circles.

The prospects for the bill, proposed by Representative Tim Murphy, Republican of Pennsylvania, are uncertain, experts say, given partisanship in both the House and the Senate and the sheer complexity of the mental health system. And its backing of the expanded use of involuntary outpatient treatment has drawn opposition from some advocacy groups.

But the bill, the Helping Families in Mental Health Crisis Act, does have more than a dozen Democratic co-sponsors in the House, and several mental health organizations are supporting it. Last week, both houses of Congress adopted one of its central provisions, expanding funding for outpatient treatment programs through other legislation. On Thursday, the House Energy and Commerce health subcommittee is scheduled to hear testimony on the entire bill, which includes more than two dozen measures.

“It’s the most comprehensive mental health bill we’ve seen in a long, long time, and that in itself is an accomplishment,” said Keris Myrick, chief executive of the Project Return Peer Support Network and president of the board of the National Alliance on Mental Illness, which supports some parts of the bill. “I think almost everyone sees things in the bill that are long overdue, but also things they’re very concerned about.”

Among those opposing the bill because of its involuntary treatment provisions is the Bazelon Center for Mental Health Law, whose president, Robert Bernstein, said, “Many serious organizations seem to have an ‘any port in the storm’ mentality, supporting this bill even though it includes dangerous provisions.”

Mr. Murphy, a clinical psychologist from Pittsburgh, put together the legislation at the behest of House Republican leaders after the massacre at Sandy Hook Elementary School in Newtown, Conn., in 2012. He spent a year hearing testimony about the current system, a patchwork of community clinics and state hospitals chronically short of funding that leaves millions of people with mental illness without treatment, often homeless or in prison.

“It’s a broken system, and we’re not going to fix it by throwing a little money here or there,” Mr. Murphy said in an interview. “We know that when people get care, they get better, but there are simply not many options: Clinics are reducing services, there are not enough psychiatrists or psychologists to go around — we found all sorts of barriers to care.”

Widely backed provisions of the bill include streamlining payment for services under the Medicaid program, and providing funds for clinics that meet standards for rigorous, scientifically supported care.

The bill also provides money for suicide prevention programs and for so-called telepsychiatry, or remote video therapy, which is seen as especially crucial in rural areas.

Provisions calling for increased training for police officers and emergency medical workers in how to identify and treat people with mental disorders are also widely approved. The police and paramedics often act as ad hoc social workers, dealing with people with mental problems when they are hurt or break the law.

About 350,000 Americans with a diagnosis of a severe mental illness like schizophrenia or bipolar disorder are in state jails and prisons, while the number of psychiatric beds available has shrunk to 35,000, according to a coming analysis by the Treatment Advocacy Center, a nonprofit group that favors expanded access to treatment.

“The situation has been getting progressively worse for 50 years, to the point where we now have 10 times more people with severe mental illness in prisons and jails than in mental hospitals,” said Dr. E. Fuller Torrey, of the Stanley Medical Research Institute, a nonprofit organization supporting research in schizophrenia and bipolar disorder, and a strong supporter of the bill.

But the bill’s backing for involuntary treatment is highly contentious. It would provide state grants for so-called assisted outpatient treatment programs under which certain mentally ill people with a history of legal or other problems get court-ordered therapy, which in most cases means trying to ensure they take their medication.

The result: more people treated earlier, and more treated against their will.

“This becomes a civil rights issue quickly, and it can drive people away from seeking services when they fear treatment will be forced on them or they’ll be locked up,” said Gina Nikkel, president and chief executive of the Foundation for Excellence in Mental Health Care, which advocates a more holistic, less medication-oriented approach to recovery.

In the last two decades, 45 states have adopted laws allowing compelled treatment in some cases, with varying requirements and levels of enforcement. Kendra’s Law, passed in New York in 1999, is one that researchers have monitored closely. One recent analysis, led by investigators at Duke University, found that since the law was passed, patients were much less likely to land back in the hospital or be arrested. Mental health and Medicaid costs for them dropped by about half.But involuntary treatment programs have led thousands of former psychiatric patients to become fierce critics of the mental health system.

Dr. Bernstein of the Bazelon Center and Dr. Nikkel said that extending such programs would “eviscerate civil right protections” and further erode trust between patient and provider.

The Murphy bill also proposes amending federal medical privacy protections — the now-familiar Hipaa laws — to allow parents or other caregivers access to a patient’s medical information.Under current law, those records are private once a person becomes an adult, and as a result, caregivers are often effectively cut out of treatment decisions. The bill seeks to bring them back in, with a provision that will also generate strong political resistance, experts said.

Finally, the bill proposes to sharply scale back many of the programs funded by the Substance Abuse and Mental Health Services Administration. This agency, with a $3.6 billion budget, has long financed programs that critics say are not backed by good evidence.

“When something has been funded for a long time, it’s tough to let it go,” Mr. Murphy said. “What we’re saying is that if a program works, then show us the evidence that it does, and we’ll keep it. If the evidence is not there, then the taxpayers shouldn’t pay for it.”

Correction: April 2, 2014An earlier version of this article misstated the name of a bill proposed by Representative Tim Murphy, Republican of Pennsylvania. It is the Helping Families in Mental Health Crisis Act, not the Helping Families in Mental Crisis Act.________________________________________________If you are affording a Silver or Gold health plan today you will not in the very near future so do not think all of this dismantling of public health access will only hit the poor and working class----it will come to all. The poor are not getting more care----they are being pushed to preventative access only where before they could access most care needed----unless you live in Baltimore. The Affordable Care Act allows for all preventative health care -----KAISER PERMANENTE MAKES NO BONES THAT ITS ALL ABOUT PREVENTION-----the middle-class will be sent into bankruptcy trying to access ordinary care and that's what Clinton neo-liberals and Bush neo-cons want to see----the goal after all is third world poverty in the US.This article is long but please glance through. Remember, all of what is described below is what the Affordable Care Act was designed to do---they want all Americans out of first world quality health care and into third world preventative care only. THAT IS FOR WHAT YOUR CLINTON NEO-LIBERAL CONGRESSIONAL POL/OBAMA WORKED. Your national labor union leaders and justice organization leaders knew and I described all this back in 2009. Baltimore's Maryland Assembly and City Hall pols worked hard to install the policies Johns Hopkins needed for these health care reform results.When people hear my say--80% and more of Americans will be on gutted of funding Medicaid for All---you see below that corporate plans will disappear to only preventative care and they are the bulk of private plans. Medicare and Medicaid already handle 1/3 of Americans.Managed care for these 80-90% of Americans will be this remote microchip/telemedicine.

THIS IS FOR WHAT YOUR LABOR AND JUSTICE LEADERS BROUGHT YOU OUT TO SHOUT FOR===THIS IS FOR WHAT MARYLAND HEALTH CARE FOR ALL WORKED FOR. GET RID OF THESE LEADERS AND POLS!

Gold standard sullied?

Employees' deductibles balloon to 80%Share This Story

Physician Praveen Arla is witnessing a reversal of health care fortunes: Poor, long-uninsured patients are getting Medicaid through Obamacare and finally coming to his office for care. But middle-class workers are increasingly staying away.

"It's flip-flopped," says Arla, who helps his father run a family practice in Hillview, Ky. Patients with job-based plans, he says, will say: " 'My deductible is so high. I'm trying to come to the doctor as little as possible. … What is the minimum I can get done?' They're really worried about cost."

It's a deep and common concern across the USA, where employer plans cover 60% of working-age Americans, or about 150 million people. Coverage long considered the gold standard of health insurance now often requires workers to pay so much out-of-pocket that many feel they must skip doctor visits, put off medical procedures, avoid filling prescriptions and ration pills — much as the uninsured have done.

A recent Commonwealth Fund survey found that four in 10 working-age adults skipped some kind of care because of the cost, and other surveys have found much the same. The portion of workers with annual deductibles --what consumers must pay before insurance kicks in — rose from 55% eight years ago to 80% today,according to research by the Kaiser Family Foundation. And a Mercer study showed that 2014 saw the largest one-year increase in enrollment in "high-deductible plans" — from 18% to 23% of all covered employees.

“People put off care or they split their pills. They do without.”

Karen Pollitz, a senior fellow at KaiserMeanwhile the size of the average deductible more than doubled in eight years, from $584 to $1,217 for individual coverage. Add to this co-pays, co-insurance and the price of drugs or procedures not covered by plans — and it's all too much for many Americans.

Holly Wilson of Denver, a communications company fraud investigator who has congestive heart failure and high blood pressure, recently went without her blood pressure pills for three months because she couldn't afford them, given her $2,500 deductible. Her blood pressure shot so high, her doctor told her she risked a stroke.

And LaRita Jacobs of Seminole, Fla., who gets insurance through her husband's job and has an annual family income of $70,000, says $7,500 a year in out-of-pocket costs kept her from dealing with an arthritis-related neck problem until it got so bad she couldn't lift a fork. She's now putting off shoulder surgery.

"How did we get to this crazy life?" asks Jacobs, 54. "We're struggling to pay our bills like we were struggling when we first got started."

Why is this happening? Many patients and doctors blame corporate greed — a view insurers and business leaders reject. Some employers in turn blame the Affordable Care Act, saying it has forced them to pare down generous plans so they don't have to pay a "Cadillac tax" on high-cost coverage in 2018. But health care researchers point to a convergence of trends building for years: the steep rise in deductibles even as premiums stabilize, corporate belt-tightening since the economic downturn and stagnant middle-class wages.

LaRita Jacobs has severe arthritis and delayed a neck surgery until it got so bad she couldn’t lift a fork. Now, she is delaying shoulder surgery that her doctor recommends and opting for less expensive physical therapy and enduring the pain. Here, she readies the needle for her weekly injection of Methotrexate, a type of chemotherapy regularly used for people with autoimmune diseases like rheumatoid arthritis.(Photo: Melissa Lyttle for USA TODAY)

"It's a case of companies trying to offer workers health insurance and still generate profit," said Eric Wright, a professor of sociology and public health at Georgia State University. "But whenever costs go up for the consumers across the board … it promotes a delay in care."

Others disagree, saying that when people pay for their care, they shop more intelligently. Chris Riedl, Aetna's head of product strategy for its national accounts, says her company's research does not indicate that insured patients are showing up sick in emergency rooms with long-neglected illnesses — which to her means, "intuitively, they're not avoiding care."

But many doctors contend it's only a matter of time before the middle class begins crowding ERs.They say putting off care can be dangerous, exponentially more costly and, if it continues and spreads, can threaten the health of the nation.

Monitoring the trend'Can I stop taking this medication?'Praveen's father, Mohana Arla, says being forced to pay so much out-of-pocket "is as good as not having insurance" in an era of ever-rising health care costs. Inpatient care last year averaged $17,553, and insurance plans require people to pay a portion of that even after meeting their deductibles, up to an out-of-pocket maximum that can easily exceed $10,000 a year for families. Median household income in the U.S. is around $53,000, and the average American has less than $6,000 in savings, according to a 2012 report by Pitney-Bowes Software. A quarter have no emergency savings at all, Bankrate.com reported in June.

Bullitt County, Ky., family practitioner Mohana Arla, right, and intern Dominique Rhymes examine Lee Curry, 54. Curry was injured while working to pull a passenger from a wrecked vehicle as a Sheriff's Department employee when his wrist was slammed in a truck door by a wind gust on Oct. 31, 2014.(Photo: Alton Strupp for USA TODAY)

"Health expenses tend to come up unexpectedly, or if you have a chronic condition, they come up relentlessly," adds Karen Pollitz, a senior fellow at Kaiser. "People put off care or they split their pills. They do without."

Mounting evidence backs that up:

• Nearly 30% of privately insured, working-age Americans with deductibles of at least 5% of their income had a medical problem but didn't go to the doctor, the Commonwealth Fund found. Around the same percentage skipped doctor-recommended medical tests, treatments or follow-ups.

• Nearly half of middle-class workers skipped health care services or fell into financial hardship because of health expenses, according to a survey by the Associated Press and NORC Center for Public Affairs Research.

• Use of hospital care among insured workers has been dropping since 2010, and use of outpatient care, such as doctor visits, dropped slightly for the first time from 2012 to 2013, according to insurance claim data analyzed by the Health Care Cost Institute.

• Medical professionals across the USA see the reality behind the research. The Arlas' patient load used to be 45% commercially insured and 25% Medicaid; those percentages are now reversed. Stan Brock, founder of Remote Area Medical, which runs free clinics around the nation, says the group's volunteer workers found that around 7% of patients who came to one of the clinics had job-provided insurance — and some waited for days just to keep a prime spot in line.

Patients often do a sort of medical and financial triage when they get sick. Jacobs, a former college professor, says every time a doctor suggests a new test, procedure or medication for her severe arthritis, she asks herself: " 'Is it critical?' You're always playing the odds. ... And I'm constantly asking my doctor: Can I stop taking this medication?"

When her shoulder started hurting a couple of years ago, she had an X-ray but put off the recommended MRI for two years. It worsened, and she couldn't move her arm without pain or lift her right hand above her head. She finally got that surgery in October but is now forgoing a shoulder procedure, opting for less expensive physical therapy and planning to "tough out the pain."

"You don't want another surgery … another bill," she says. "It may be more of a problem later, but that's the risk you take."

While all out-of-pocket expenses play a role in such decisions, experts say the driving factor is the deductible, which averages $2,000 or more for single coverage for nearly one in five workers and from around $2,000 to $4,500 for families, depending on the type of plan. Companies may help fund health-savings accounts to pay some of these costs, sometimes with only a few hundred dollars.

"I can remember when $1,000 was considered a high-deductible plan. Now that's become kind of the norm," Pollitz says. "We're kind of in high-deductible land."

The cost shift extends to workers in government jobs, long known for bountiful benefit packages. Lee Curry, a sheriff's deputy in Bullitt County, Ky., says his county health plan comes with a $1,500 deductible, which keeps him from going to the doctor at all.

"Health insurance doesn't cover much of anything until you cover your deductible," says Curry, 54. "It puts a burden on you. You've got to have the money to be seen."

Is Obamacare to blame?Stagnant salaries also skew budgetsSince the ACA took effect, "there's been an accelerated movement" to these types of health plans, says Brian Marcotte, president and chief executive officer of the Washington, D.C.-based Business Group on Health.

Marcotte, whose group represents 400 large employers, says that the looming Cadillac tax is one factor but acknowledged that managing health care costs is another.

Companies have cited the ACA for cutting medical benefits in other ways. For example, United Parcel Service partly blamed the law when it removed thousands of spouses from its plan because they are eligible for medical coverage elsewhere.

But DeAnn Friedholm, director of health reform for Consumers Union, says she's skeptical when employers point to the ACA. "This isn't new," she says. "Companies have been cutting back on benefits and cutting costs for decades."

Sara Collins, vice president for Health Care Coverage and Access at the Commonwealth Fund, says two ACA requirements — keeping children under 26 on their parents' plans and covering preventive care — didn't add much to companies' health care tabs, partly because most already covered preventive care such as physicals and mammograms. Pollitz says the ACA actually holds down the consumer burden by capping out-of-pocket expenses at $6,300 a person — which, although that amount is "more than most people have in the bank," is better than no cap at all.

Experts point out that the ACA requires preventive care to be covered fully and exempt from deductibles — although surveys show many workers still forgo screenings and physicals because they're unaware of this or know they can't afford follow-ups if illnesses are found.

Several experts say the consumer crunch has less to do with the health system overhaul than stagnant salaries. The average hourly wage is nearly identical to what it was 50 years ago in today's dollars: $19.18 in 1964 compared with $20.67 in 2014, according to U.S. Bureau of Labor data analyzed by the Pew Research Center. Meanwhile, U.S. health spending ballooned from 5% of gross domestic product in 1960 to 17% in 2013.

Physician Praveen Arla says he's seen a role reversal since the implementation of the Affordable Care Act. Middle-class patients are now avoiding regular care due to high-deductible plans and out-of-pocket expenses. VPC

"People are very close to the line in terms of their budgets," Collins says. "What consumers are really seeing is their incomes have grown even slower than the slower growth in health care costs" in the past few years.

Insurers also blame the cost of care, saying that can't be absorbed just by premiums. But Wilson and other patients put much of the blame on insurers.

"Insurance is all about the dollar," Wilson says. The never-ending cost shift to consumers "is something that basically all kinds of people screwed up. … Obamacare is a step in the right direction. But it's not enough. I expected more out of it than I got."

The ugly side effectsA spiral of painful debtWhen consumers skip care, they enter a downward spiral that imperils their physical and financial health.

Jennifer Ross, an arthritis sufferer in Florida insured through her husband's job, says she recently made the wrenching decision not to take a medication that might allow her to get around without her wheelchair. The $2,400-a-month medicine would cost her $600 a month out-of-pocket even with insurance, and she simply can't swing it. To make matters worse, Ross' 12-year-old daughter was recently diagnosed with arthritis, too.

"It's a no-win situation," Ross says.

Surgeon Paul Ruggieri of Fall River, Mass., says his patients with high-deductible plans often blanch at the out-of-pocket cost to electively treat two common ailments he sees regularly — gallstones and hernias — until they become potentially dangerous and costly emergencies.

If the procedures are done electively, patients are required to pay half of the cost upfront; a hernia repair done laparoscopically would cost about $4,000 at a surgery center. That's often about the amount of some patients' deductibles, so they would have to pay the full bill out-of-pocket. If the procedure is done at a hospital, even laparoscopically, it can cost as much as $17,000. If patients delay and are rushed to the emergency room for the procedure, the hospital would charge at least two to three times the amount of the surgery, Ruggieri says. It would also mean a two- to three-day hospital stay vs. two hours for the elective procedure, and much longer at-home recuperation.

Paul Ruggieri, with medical assistant Monica DePonte, is a surgeon who sees a lot of hernia and gall bladder patients who put off care until it becomes an emergency.(Photo: Josh T. Reynolds for USA TODAY)

Ruggieri sees the same issues with gallstones, which are simple to treat electively before they get so painful a patient can't stand it anymore and heads to the ER.

When patients do get needed care, some find themselves in massive debt. Kim Brown, an administrative assistant in Louisville who was earning about $40,000 a year, owes many thousands — the bills are still coming, so she doesn't know exactly how much — after battling thyroid cancer. She says her annual out-of-pocket costs are $7,500, and she also has to pay 15% for things like hospital stays. No longer able to work because of her illness, she reluctantly signed up for Medicaid and will likely declare bankruptcy.

'Skin in the game'The push for preventive care"I've worked for 35 years. I never wanted to go on Medicaid," says Brown, 50. "It's horrible. I paid for insurance for all those years, and still ended up in this situation."

But insurers, employers and others say that such stories are the exception and that high deductibles generally encourage consumers to seek the best value for their dollar.

"By having deductibles, it puts skin in the game," says Divya Cantor, senior clinical director for the insurer Anthem in Kentucky.

Joel Diamond, a Pittsburgh primary care doctor, thinks high-deductible plans are a smart choice for people who can't afford higher premiums and are generally in good health.

He cites the case of a young woman who couldn't afford insurance on her own who stopped having periods and went to the emergency room with severe headaches. Diamond discussed doing testing for possible ovarian and endocrine problems. When blood work showed abnormal levels of the hormone prolactin, he recommended an MRI to rule out a pituitary tumor. Her bill for just a few hours in the emergency room was $15,000, something that will take her years to pay off.

If she had had a high-deductible plan, he says, it would have paid for a large chunk of the cost, and her debt could have been a third to half as much.

"We don't have car insurance for windshield wipers and oil changes, but we need it for the catastrophic stuff, just like our health care," says Diamond, who is also chief medical officer for the health care IT company dbMotion.

Aetna's Reidl says her company allows people to compare prices easily on its website. Some tests, for example, could cost hundreds of dollars or less at some hospitals and thousands at others.

Aetna, the first national insurer to move to high-deductible plans — which it coined "consumer-directed plans" — more than a decade ago, says the plans help employees and employers save money.

Reidl says she has heard the criticism that they "may cause some individuals to put off care," but counters that Aetna members with these plans get routine preventive care and screenings at higher rates than those with other plans. And their employers save an average of $208 per employee per year after they switch to high-deductible plans.

"We've seen that over 10 years consistently," she says.

Aetna recommends companies pair the plans with health reimbursement or savings accounts — which allow employees to set aside tax-free money to use for cost sharing — to ease the burden of out-of-pocket costs on employees.

But Wendell Potter, who used to work in public relations in the insurance industry and has since written a book about the experience called Deadly Spin, says insurers who study high-deductible plans are "not disclosing everything they find."

"They do these reports based on their populations to try to sell more of these plans to employers," he says. Population-based reports don't necessarily reflect the fact that "individuals and families are having to file for bankruptcy because they are in their plans."

Potter left his public relations job at Cigna in 2008 in part because "I was expected to be a champion" of high-deductible plans. He says these plans are "taking us in the wrong direction ... back to a system that we would have thought the ACA prevented."

The futureWill time heal all?There are no signs high deductibles are going away.The Centers for Medicare and Medicaid Services last month cited these plans as one of the reasons health care spending hit a record low in 2013. But CMS statistician Micah Hartman says his office is "not looking forward to what the impact would be going forward" if consumers who delay care need far more expensive emergency care later.

Meanwhile, experts say Americans will need to take further steps to control their health costs.

Wilson, the Denver patient, says that after her doctor scolded her for stopping her blood pressure pills, she now takes them daily. But keeping up with her six medications is a constant struggle given her $33,000-a-year income, so she copes by asking for samples from the doctor, using a prescription discount plan and sometimes buying just a few pills at a time.

Doctors and doctor groups say such individual coping strategies can be helpful, but action is needed on a national level. The American Academy of Pediatrics recently came out with a policy statement saying high-deductible plans "may be a less desirable way to lower health care costs than other means … even if 'other means' require more work by government, insurance companies and other health policy participants."

They say policymakers should consider requiring that the plans cover only adults, not children, as adults may suffer more from reduced care. The group also suggests exempting outpatient care from deductibles and requiring employers to put a lot more money in health-savings accounts that go with the plans.

Oncologist Ezekiel Emanuel, the former special adviser for health care policy to the director of the Office of Management and Budget, says insurers and employers moved to high-deductible plans rather than trying to come up with "a more intelligent plan design."

Emanuel, who is considered an architect of Obamacare, says that he is "not a fan of high-deductible plans" and that what's needed are "smart deductibles" that don't discourage people from using the services they really need to stay healthy. He cites the preventive care visits that aren't subject to deductibles under the ACA.

Higher deductibles, he says, should apply to "discretionary services" like knee replacements and low or no deductibles should be for important treatment such as for insulin or ophthalmologist visits.

But Wright, the Georgia professor, says he doesn't see any major changes on the near horizon.

"I wish I could be optimistic, but I'm not sure," he says. "There's a lot of reason to be worried about the future."